GW1-2022-04337_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATERZONES
cu
Y FROM TO DESCRIPTION
Well Contractor Name ��/ n 350 f`• 355 f` 1 gpm
2465-A 450 fL 460 f`• 3 gpm
NC Well Contractor Certification Number 7 15.OUTER CASING for multi cased wells OR LINER if a litahle
APR 11 202_ FROM TO DIAMETER THICIZTIEss MATERIAL
Derry's Well Drilling, Inc. _ 0 ft. 47 ft- 61/8 SDR-21 I PVC
Company Name R R ° nGt^C1,1��itil 16.INNER CASING OR TUBING eotheiwal dosed-loop)
2.Well Construction Permit#:
357054y ' �IJAi�^'T' FROM TO DIAMETER THICKNESS MATERIAL
fL ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
ft fL in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) h• ft to
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 f`• 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 it Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Storrnwater Drainage fL %
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if mcessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,saiVrock sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 12 ft Red Dirt
4.Date Well(s)Completed: Well ID#
8�2�2� 12 f`- 30 ft Brown Dirt&Rock
30 a- 485 f`- Blue Rock
5a.Well Location: fL R•
Patrick Dennis R• fL
Facility/Owner Name Facility ID#(if applicable) fL ft Seams: 65',80', 115',225',330',
888 Jones Pond Rd, Polkton 28135 ft. ft. 350'=1g,426,450'=39
Physical Address,City,and Zip 21.REMARKS
Anson 6429-00-39-4696
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient) W 96�& /
N W 1e/ 8/16/21
Sign re of Certified Well Contractor V Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same cortstruetion,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 485 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijfereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
52 (tL) W Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 On.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary. 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form;within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb• well construction to the county health department of the county where
constructed.
t
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013